Updated 24 November 2025
Date of Assessment: Remote Clinical Searches were carried out on 17 December 2025 and the site visit took place on 19 December 2025.
The legal status of Belmont Health Centre is a partnership since its CQC registration in 2013. It merged with another GP practice (The Enterprise Practice) in January 2023. The practice was last assessed in July 2018. This comprehensive assessment was undertaken because of the length of time since the last assessment.
Belmont Health Centre is a GP Practice and delivers General Medical Service (GMS) to approximately 19,250 patients in the London Borough of Harrow under a contract held with NHS England. The National General Practice Profile stated that the population make up for this location is 46.0% Asian, 36.1% White, 7.8% Black, 3.4% Mixed and 6.9% other non-white ethnic groups.
Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population is in the 7th decile (7 of 10). The lower the decile, the more deprived the practice population is relative to others. This practice is in a higher decile indicating it is in a less deprived area on the national scale. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
There was a branch surgery located at 252 Long Elmes in the London Borough of Harrow which was not in use at the time of the assessment due to structural issues.
SAFE: Staff could raise concerns and understood risks and how to manage them. People were protected and kept safe; however, not all patients with safeguarding concerns had alerts on the records of their household members within the clinical system. The facilities and equipment met the needs of the people, were clean and well maintained. Risk assessments were carried out but action plans were not followed up in a timely manner such as those of fire safety and Legionella risk assessments. Learning from complaints and significant events were not always recorded and shared with staff and recorded in staff meeting minutes. Managers completed regular appraisals at the appropriate time for the staff. Medicines were not always managed well but the service involved people in planning for any changes. Emergency medicines and equipment were provided and well-maintained. Fridge temperature checks were monitored and records maintained. Blank prescription forms were stored securely and appropriately.
EFFECTIVE: People were involved in assessments of their needs, however, health check reviews for people with learning disability were not always comprehensive. Not all patients identified as carers had their health checks completed. Clinical searches findings identified ineffectiveness of the service in assessing patient needs. Staff worked with all agencies involved in people’s care for best outcomes. Staff made sure people understood their care and treatment to enable them to give informed consent.
CARING: People had mixed feedback about being treated with dignity and respect; kindness and compassion. Staff protected the privacy of the people.
RESPONSIVE: The service provided information people could understand. Not all patients we spoke to, knew the process to follow when making complaints. However, staff knew how to support patients with their complaints and signpost them to the website to give feedback or listen to their verbal complaints.
WELL- LED: Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, approachable and supporting staff to develop their roles. Staff understood their roles and responsibilities. However, we found concerns with administrative oversight of daily practice schedules which included a lack of effective system to monitor staff training and complete action plans recommended from risk assessments. The clinical search findings showed a lack of effective systems and process to monitor and assess patient needs to mitigate the risks associated with their health conditions. There was no evidence that the Patient Participation Group (PPG) was adequately structured to ensure improvement to service delivery.
We found breaches of regulation in relation to safe care and treatment (regulation 12) and good governance (regulation 17). In instances where the Care Quality Commission (CQC) has begun a process of regulatory action, we may publish this information on our website after any representations and /or appeals have been concluded, if the action has been taken forward. We have asked the provider for an action plan in response to the concerns found at this assessment.